Functional Insulin Treatment: Principles, Teaching Approach and Practice

1 Introduction.- 2 Overview of the Phases of Rehabilitation in Persons with Type I (Insulin-Dependent) Diabetes.- 2.1 Intermezzo 1: A Strategy for Failure - or How Not to Educate Patients.- 3 Basic Diabetes Education (Phase I of Rehabilitation).- 3.1 Action in Healthy Persons Deficiency.- 3.2 Diet.- 3.2.1 Goals of Dietary Counseling.- 3.2.2 Estimating the Carbohydrate Content of Food.- 3.2.3 Prandial Requirement in Relation to Type and Quantity of Food.- 3.2.4 Counting Calories and Maintaining Body Weight.- 3.2.5 Teaching Tips.- 3.2.6 Problems in Dietary Counseling.- 3.3 Self-monitoring.- 3.3.1 Self-monitoring of Blood Glucose and Targets for Glycemic Control.- 3.3.2 Self-monitoring of Urine Glucose.- 3.3.3 Determination of Acetone in Urine.- 3.3.4 Targets for Glycemic Control.- 3.4 Strategies for Treatment.- 3.5 Insulin.- 3.5.1 Pharmacokinetics.- 3.5.2 Delivery.- 3.5.3 Special Aspects of the Practicability of Delivery.- 4 FIT Training (Phase II of Rehabilitation).- 4.1 Initial Algorithms, K and the Blood Glucose Target Value.- 4.2 Intermezzo 2: A Strategy for Failure - or How to Demotivate Even the Most Convinced Enthusiast.- 4.3 Introducing FIT in Practice.- 4.4 Pedagogical Aspects of Substitution: Transactional Analysis and Insulin Games.- 4.5 Is Yielding to Temptation All Bad?.- 4.6 Testing Algorithms for Correcting Blood Glucose (and Determining the Kidney Threshold for Glucose). Why?.- 4.7 Why fast?.- 5 Criteria for Functional Treatment.- 5.1 Basal Substitution.- 5.1.1 Basal Insulin.- 5.1.2 Fasting Hyperglycemia and Compensation of Circadian Variation in Requirements.- 5.2 Prandial Substitution - Problems in Dosing Regular Insulin.- 5.3 Self-monitoring and Glycemic Control - Why Keep Records?.- 5.3.1 Record Keeping, Analysis and Evaluation of the Daily Net Result.- 5.3.2 Coping with Practical Problems.- 5.3.3 Frequency of Acute Complications.- 5.3.4 Contingence of Dose and Carbohydrate Intake on Measured Blood Glucose Level.- 6 Hypoglycemia.- 6.1 Definition of Hypoglycemia.- 6.2 Increased Probability of Severe Hypoglycemia.- 6.3 Causes of Hypoglycemia.- 6.4 Prevention of Hypoglycemia.- 6.5 Treatment of Hypoglycemia.- 7 Hyperglycemia.- 8 Rules for Algorithm Modification.- 8.1 Global Changes in Requirement.- 8.1.1 Global Decrease in Requirement.- 8.1.2 Global Increase in Requirement.- 8.2 Modification of Individual Algorithms.- 8.2.1 Modifying the Algorithm for Basal Insulin.- 8.2.2 Modifying the Algorithms for Prandial Insulin.- 8.2.3 Modifying the Algorithms for Correcting Blood Glucose Excursions.- 8.2.4 Modifying the Target Values for Current Blood Glucose and Target Range for Mean Blood Glucose.- 8.2.5 Interdependence of Algorithms.- 9 Physical Activity.- 9.1 Short, Sporadic Periods of Physical Activity.- 9.1.1 Physical Activity not Preceded by a Recent Injection of Regular Insulin.- 9.1.2 Physical Activity after Regular Insulin.- 9.1.3 Further Influences.- 9.2 Prolonged Periods of Physical Activity.- 10 Pregnancy in Type I (Insulin-Dependent) Diabetes.- 10.1 Patient Education Concerning Diabetes and Pregnancy.- 10.2 Consequences for Treatment.- 10.3 Interdisciplinary Care for Pregnant Diabetic Women.- 10.3.1 Diabetological Care: FIT.- 10.3.2 Obstetrical Care.- 10.3.3 Ophthalmological Care.- 10.3.4 Neonatal Care.- 10.4 Special Aspects of Secondary Adjustment of Dosage During Pregnancy and Childbirth.- 11 Functional Treatment for Type II Diabetes.- 11.1 Characteristics of Treatment of Type II Diabetes.- 11.2 Covering Basal Requirements in Insulin-Treated Type II Diabetic Patients.- 11.3 Special Aspects of the FIT Training Program for Type II Diabetic Patients.- 11.4 How Can Weight Loss Be Reached with Type II Diabetes During Functional Treatment.- 12 Coping with Special Situations.- 13 Frequent Patient-Related Problems.- 13.1 Grief-Work in Persons with Diabetes.- 13.2 Inadequate Information.- 13.3 Failure to Adjust to the Realities of Diabetes.- 14 Frequent Physician-Related Problems.- 14.1 Communication Problems.- 14.2 Inability to Understand What Life Is Like for the Patient.- 14.3 Inadequate Information.- 15 The Contras.- 15.1 Contraindications for Functional Treatment.- 15.2 Difficult Patients.- 15.3 Intermezzo 3: A Strategy for Failure or How to Mess Things Up in the Outpatient Phase.- 16 Checklist for Continuing Care of FIT Patients (Phase III of Rehabilitation).- 16.1 The Patient's Knowledge.- 16.2 Applying Knowledge Practicability of Therapeutic Measures.- 16.3 Motivation.- 16.4 Acceptance of Diabetes.- 16.5 Metabolic Status.- 16.6 Late Complications.- 16.7 Comorbidity.- 16.8 Social Environment.- 16.9 The Patient's Contact with the Diabetes Treatment Center, Physician or Diabetes Counselor.- 16.10 Humor.- 17 Review of Results and Experience.- 17.1 Patients.- 17.2 Follow-up.- 17.3 Results.- 17.3.1 Acceptance of FIT.- 17.3.2 Metabolic Control.- 17.3.3 Acute Complications.- 17.4 Experience with FIT in Special Situations.- 18 Open Questions, Unsolved Problems and Limits of FIT.- 19 Epilogue.- References.- Appendix 1: Didactic Aspects of the FIT-Training Program.- Appendix 2: FIT - Initial Information for Patients.- Appendix 3: Nomogram for Generating the Initial Algorithms for FIT/Coauthors: H. Egger and H. Thoma.- Appendix 4: Selection of Available Human Insulins.- Appendix 5: Examples of Carbohydrate Units.